Healthcare Provider Details

I. General information

NPI: 1396514923
Provider Name (Legal Business Name): CINDY SAMPLE PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/22/2023
Last Update Date: 12/22/2023
Certification Date: 12/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8150 LEESBURG PIKE STE 740
VIENNA VA
22182-7700
US

IV. Provider business mailing address

8150 LEESBURG PIKE STE 740
VIENNA VA
22182-7700
US

V. Phone/Fax

Practice location:
  • Phone: 703-397-7680
  • Fax:
Mailing address:
  • Phone: 703-397-7680
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0904003947
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: